A Comprehensive Approach to Improving Emergency Obstetric and Newborn Care in Kigoma, Tanzania

Efforts to increase the availability and utilization of high-quality emergency obstetric and newborn care and routine delivery care services in Kigoma were successful and subsequently contributed to significant reductions in maternal and perinatal mortality in the region.

MMR of 211 per 100,000. 1 In the last decade, to combat maternal mortality, governments, global partnerships, and other stakeholders have promoted evidence-based interventions, packages of effective services, strategies, and policies with specific targets. [2][3][4][5][6][7][8][9][10][11][12][13] However, there are few documented examples of these approaches being adapted to the realities of rural communities and successfully implemented in high-mortality countries in Africa. [14][15][16][17][18][19][20] One recent example comes from the Program to Reduce Maternal Deaths in Tanzania. When it began in 2006, the MMR in Tanzania was estimated to be 578 maternal deaths per 100,000 live births, one of the highest in the world at that time. 21 Maternal mortality was high because highquality emergency obstetric care was not available or accessible to many women, and more than half of women delivered at home without skilled birth attendance (53%), among other factors. [21][22][23][24][25][26] Tanzania was also experiencing a severe shortage of health providers capable of providing emergency obstetric and newborn care (EmONC). [26][27][28][29][30] Perinatal mortality, for many of the same reasons, was also high (42 per 1,000 births). 21 The same issues were even more severe in remote regions in the country. 22 The Program aimed to reduce maternal mortality in underserved communities by improving women's access to EmONC through task sharing and by extending more services, including obstetric surgery, to the health center level. The Program focused its work in Kigoma-one of the most underserved regions at that time. 21 While the Program's main focus was on EmONC, new components were added over time to further improve quality, strengthen referral systems, and create demand for maternal health services. All program strategies were in line with and designed to contribute to the Tanzania Ministry of Health's strategies and goals to reduce maternal and neonatal mortality, including ensuring that 80% of deliveries are in health facilities and 100% of hospitals and 50% of health centers provide CEmONC. 31,32 We present the Program's maternal healthrelated interventions and obstetric results from

Sustain Availability of High-Quality CEmONC
Mentorship, supportive supervision, and continuing medical education are essential, especially for newly trained associate clinicians responsible for managing the full range of obstetric complications without the presence of a more experienced clinician in the facility. The Program's extensive support included: (1) on-site supervision and mentorship visits; (2) off-site continuing medical education workshops targeting skills improvement to manage identified problems; (3) weekly calls led by expert obstetricians to discuss obstetric cases, share challenges and feedback and to analyze maternal near-miss cases; (4) a 24/7 emergency call system staffed by expert obstetricians; and (5) an e-learning platform to help providers continuously improve their knowledge and clinical decision-making skills on the management of obstetric emergencies. 36 These multiple forms of support fostered the development of strong relationships and trust between health providers and their mentors.
Clinical audits were used to monitor and improve the quality of care in supported health centers and hospitals and covered the justifiability of cesarean deliveries and vacuum extractions and circumstances around maternal deaths, stillbirths, neonatal deaths, and maternal near misses (neardeath experiences due to complications that occurred during pregnancy, childbirth or within 42 days after birth). Audit findings were discussed with health providers and local government health managers and used to devise concrete actions to reduce preventable deaths and morbidities. Near miss audit results were used to boost health providers' morale and to reinforce good decision making and readiness. Initially conducted monthly in 2009-2012, the audits, along with supportive supervision visits became quarterly once health providers became more confident and health facilities improved their CEmONC services. Additional capacity building was provided as needed on topics such as leadership, management, planning, and budgeting.
Project funds were used in supported facilities, when necessary, to cover the cost of repairing equipment and infrastructure and for essential supplies and drugs. While the Program worked toward identifying and addressing some of the systemic problems affecting issues like drug supply, it was still important to ensure that newly trained health professionals had what they needed to continue mastering their obstetric and surgical skills. As implementation continued over the years, additional infrastructural improvements were needed at health centers and hospitals including renovations of operating theaters. Through 2017, essential equipment was also maintained, repaired, and/or replaced when needed, and districtbased biomedical equipment technicians were trained to service obstetric care-related equipment.
The program upgraded 13 health centers by building operating theaters, renovating maternity wards and laboratories, and improving access to water and electricity.  Support and sustain good quality EmONC at regional, district, and community levels Strengthen hospitals to back up and serve as resources for health centers Construction of new operating theaters and renovation of maternity wards at 3 supported hospitals Include regional and district level health officials in routine supervision and mentorship visits to supported facilities Approximately 50 district council and regional health officials participated Form and train a regional mentorship team 1 regional mentorship team created with 36 members (obstetrician-gynecologist, medical officers, AMOs, and NMWs).
Strengthen capacity of district councils to plan, budget, manage, and support EmONC service delivery 16 district council members trained Improve quality and use of data for decision making through training of providers and district and regional councils 60 individuals from hospitals, health centers, and regional and district councils trained in data for decision making (a series of 4 workshops), ICD-10 codes and maternal mortality (1 workshop), and data quality (1 workshop) To address chronic human resource shortages, the Program worked with the government at all levels to secure more clinicians, doctors, and nurse-midwives to be posted in Kigoma; recruited retired nurse-midwives in Kigoma to rejoin the workforce; and trained medical attendants (health workers without formal training in skilled birth attendance) as part of the maternity ward team. To help retain staff, the Program constructed goodquality houses for health providers working at supported hospitals and health centers.
The following additional interventions were added to the Program based on needs identified in facility and population-based assessments.

Improve Newborn Care
To strengthen the capacity of maternity ward teams to provide newborn care, in 2016, the Program implemented a 6-month pilot consisting of low-dose, high-frequency trainings in neonatal resuscitation (Helping Babies Breathe 37 ) and overall newborn care in 5 program-supported (PS) facilities. The same approach was expanded to all PS health facilities in 2017. The Program also collaborated with a Ministry of Health team to train providers in PS health centers on kangaroo mother care (KMC) to keep premature and low birthweight babies warm.

Improve Quality of Skilled Birth Attendance and Elements of BEmONC at Dispensaries
In 2013, the first CDC/DRH evaluation showed that many women were delivering at dispensaries. In partnership with the local government, the Program selected, renovated, and, beginning in 2016, supported 18 dispensaries to deliver highquality skilled birth attendance and some elements of BEmONC, as well as family planning and comprehensive postabortion care (CPAC). To improve services, 39 health providers (enrolled nurses, nurse-midwives, and clinical officers) were trained and then mentored by Thamini Uhai and the in-charges of the closest health centers. An additional 49 dispensaries were renovated and equipped for essential maternal and newborn care, and/or supported by the Program with a focus on family planning services.

Strengthen Referral Systems
To increase women's access to EmONC, a pilot referral project conducted from 2015 to 2017 linked a PS health center with adjacent dispensaries and communities and increased communities' preparedness and health providers' readiness to respond to obstetric complications. The Program worked with communities and health providers to develop referral guidelines; improve the readiness

Strategy and Interventions Scope
Urge government officials at the national, regional, and district levels to send more health providers to Kigoma, increase budget ceiling for health centers offering CEmONC and sustain good-quality service delivery after project end National: frequent meetings with the Ministry of Health, PO-RALG, and relevant members of parliament Regional: routine meetings with regional health management team members and regional medical officer District: routine meetings with district health management councils and district medical officers Strengthen accountability for good-quality service delivery Identify and engage champions (local council members, members of parliament) Share information with communities so that they can contribute to sustaining good-quality service delivery after project end Conducted 83 meetings with communities in catchment areas surrounding supported health facilities.
Use media to promote program achievements, advocate for sustainability of program activities, and elevate maternal mortality as a priority in Tanzania  of facilities to send/receive referrals; establish village-level community savings accounts to pay for transport and other referral costs; establish a free telephone network for communities, community health workers, and health providers to communicate about obstetric referrals; and increase the availability and accessibility of motorized transport for obstetric referrals by fostering partnerships with local transport providers. The referral project was scaled up in 3 catchment areas in 2 additional districts in 2017.

Implement Birth Companionship to Improve Experience of Care for Women
In 2017, the Program launched a 2-year pilot project that introduced birth companionship in 9 PS facilities. 38 Birth companionship has been shown to improve women's experience of care during childbirth, among other positive benefits. 39,40 During the pilot, women were offered the choice of having a female companion to stay by their side throughout childbirth. Birth companions were oriented to provide continuous informational, practical, and emotional support.

Increase Demand for Facility Delivery and Improve Birth Preparedness
Despite improved availability and accessibility of high-quality EmONC services, program data showed that many women were not using health facilities for delivery. In response, between 2014 and 2019, the Program developed and supported 2 tested, evidence-based mass media campaigns to create demand for maternal health services and to increase birth preparedness. The first campaign aired in October-December 2014 and May-July 2016 and focused on the risks of home delivery; pregnancy danger signs; the importance of birth preparedness; and, while realistically considering structural barriers, the benefits of facility delivery. A second campaign launched in 2018 reiterated the messages of the first campaign and added birth companionship messages. Both were multiplatform campaigns that featured hard-hitting radio spots; outreach by community health workers; interpersonal communication; printed materials; and outdoor, social, and earned media. The second campaign included a 12-part radio magazine show. The Program also recruited, trained, and supported 139 community health workers to mobilize communities; provide maternal and reproductive health education; further link communities with health services; and help communities be more prepared for obstetric emergencies. Support and Sustain High-Quality EmONC at Regional, District, and Community Levels To sustain routine clinical support, the Program formed a regional mentorship team to continue providing the types of clinical support that the Program had been providing. The team was made up of 36 committed and experienced clinical experts selected from PS facilities who were trained to conduct simulation sessions and clinical audits. They were also trained on the principles of mentorship and the elements of respectful maternity care. The Program accompanied the mentorship team for 4 rounds of mentorship, and in 2019, the team began conducting mentorship visits on their own.
To financially sustain service improvements in the final years before the program transition, the Program worked with the government, health facilities, and communities to prepare budgets that incorporated key maternal health program components, while supporting efforts to increase budget allocations at the national level. 41

EVALUATION METHODS
The outcomes and impact of the Program were evaluated from 2013 to 2019 with objectives to (1) assess capacity, functionality, effective coverage, and quality of routine and EmONC care; and (2) measure maternal and newborn outcomes. In 2013, the Program established a comprehensive data system for monitoring and evaluation throughout the region, complementing the aggregated routine health management data reported to the Ministry of Health. The system included periodic data collection from all public and private health facilities that conducted at least 90 deliveries per year, regardless of program-support status. Between 2013 and 2019, the number of facilities providing delivery care included in the assessment increased substantially, as a reflection of increased facility-based care at birth in the region. Originally, 127 health facilities were included in the 2013 evaluation and were revisited in subsequent years. The latter evaluations also included facilities that had recently started to provide delivery care and thus were not captured in 2013 (47 added in 2016 and an additional 23 in the 2018 and 2019 evaluations). This approach allowed the assessment of the system-wide increase in capacity and functionality of maternal care services and its relationship with pregnancy outcomes. When compared to the routine health

Health Facility Assessments
The health facility assessments (HFAs) evaluated facility infrastructure, availability of equipment and supplies, essential drug stocks, staffing, ability to provide routine obstetric and newborn care, capacity to collect routine maternal and child health data, and performance of EmONC interventions. 43 The assessments were first conducted in 2013, and all HFAs were conducted by CDC personnel and Tanzanian data collectors. Subsequent assessments took place in January 2016, January 2018, and February 2019. 43 Availability of services and items that are essential for obstetric and newborn care were assessed by observation and direct verification. EmONC functionality was assessed based on the performance of the EmONC signal functions 44 in the 3 months before the data collection. A detailed description of the assessment methodology can be found elsewhere. 43 The health assessment questionnaire is included in Supplement 1.

Pregnancy Outcome Monitoring Studies
In 2013, CDC developed a system and tools (Supplement 2) for periodic data collection of all births that occurred in health facilities providing maternity care in the region. 43 The approach was designed to collect individual observations on all women who delivered in the facilities where the HFAs were conducted. Information on each delivery included maternal characteristics, the obstetric diagnosis, delivery type and outcome, newborn characteristics and care, obstetric surgeries, postpartum pregnancy complications, and status of mother and baby at discharge. Data were extracted from all available inpatient logbooks, patient records, audits, and morgue registers. In hospitals and health centers, individual patient data were triangulated across various sources-such as labor and delivery, postpartum, female ward, surgical, admission/discharge registers, and hospital morgues-to ensure completeness of information. In dispensaries, where only the maternity service statistics register documents delivery and postpartum events, individual data did not need triangulation; however, in a few instances, maternal or perinatal deaths that occurred in dispensaries were identified in audit data performed at the hospital or district level; these outcomes were linked to the dispensary of occurrence. Data were collected retrospectively for 12-30 months at a time using specially designed inventory and data extraction and triangulation tools. Information on women with direct and indirect obstetric complications was classified according to ICD-10 standards. Women with multiple complications were classified according to their most severe direct obstetric complication; if they only suffered indirect obstetric complications, they were classified according to the most severe indirect complication. 45 Facility-based maternal deaths were identified among all female deaths that occurred in the facility using all registers available at admission and discharge, all relevant wards, operating rooms, and the morgue. The number of data sources, their quality, and completeness improved over time. Additionally, in 2015, the Ministry of Health introduced facility death registers in all hospitals and health centers. Death registers were kept on each ward and captured individuals' information related to age, sex, and cause of death. Tallied monthly, the quality of maternal and neonatal mortality data gradually improved. The percentage of maternal deaths with unspecified cause of death, for example, declined from 10% to 2% between 2013 and 2018. All information related to maternal deaths collected from service statistics sources were reviewed by 2 CDC obstetricians and 1 Tanzanian medical doctor not associated with the implementation activities.
Perinatal deaths were originally extracted from registers maintained in labor and delivery, postnatal and neonatal wards, and the morgue. Data inventory and tools were expanded in 2018 and 2019 to capture additional registers: the death registers, which also captured perinatal deaths; registers in newly opened neonatal intensive care units and Kangaroo Mother Care corners; and, a separate morgue stillbirth and newborn death register. Thus, the enumeration of perinatal deaths was likely to be more complete for 2016-2018 than in earlier periods.
We describe the evaluation results from data collected in 2013, 2016, and 2019. Data collected in 2013 refer to EmONC performance and outcomes in 2013, those collected in 2016 refer to performance and outcomes in 2016, and those collected in 2019 refer to performance and facility pregnancy outcomes in 2018.

Population Denominators
Using the total population figures for Kigoma region from the 2012 Population and Housing Census and the region-wide growth coefficient, we estimated the total population for 2013 and

Measures
For our analyses, we focused on measures related to the availability of routine and emergency obstetric care and indicators recommended to assess coverage, utilization, and quality of EmONC services. 44 We also assessed essential obstetric and newborn care capacity using: (1) general facility infrastructure (in terms of availability of uninterrupted power supply, clean and safe water supply, communication and emergency transport availability); (2) availability of trained staff (at least 1 staff member trained in EmONC in the previous 1-3 years); (3) availability of supplies and essential medicines; (4) performance of routine maternal care (services available 24/7, use of partographs, and use of active management of the third stage of labor); (5) performance of essential newborn care (initiation of immediate breastfeeding, skinto-skin, and promotion of kangaroo mother care); and (6) availability of protocols, guidelines, and forms needed for conducting service delivery. EmONC services are defined by a set of lifesaving interventions, or "signal functions," recommended by the World Health Organization (WHO) to treat the major direct obstetric complications. 44 BEmONC interventions include administration of parenteral antibiotics, uterotonics, and parenteral anticonvulsants; manual removal of placenta (MRP); removal of retained products; assisted vaginal delivery (AVD); and basic neonatal resuscitation. CEmONC includes 2 additional services: performance of obstetric surgeries (e.g., cesarean delivery) and performance of blood transfusion. Facilities were classified based on whether they had, within the previous 3 months, performed each of these signal functions. Because AVD-using either forceps or vacuum extractoris relatively uncommon in Tanzania, some facilities were classified as CEmONC or BEmONC even if they did not perform AVDs within the past 3 months (i.e., CEmONC-1 and BEmONC-1). Facility assessors looked at evidence of whether each of the EmONC signal functions had been used in the 3 months before the study, if the required drugs and/or equipment were present, and if health providers at the facility had the training to perform the service. Evidence of all these elements was required to record that a signal function was performed/available. We examined indicators of EmONC utilization, as recommended by WHO, 44 (institutional delivery rate, population cesarean delivery rate, met need for obstetric care, and direct obstetric case fatality rate [CFR]) and other key outcome indicators (facility maternal and perinatal mortality, neonatal and stillbirth rates) in 2013 and 2018 and compared them by facility type and program support status. Program support status was defined based on the receipt of various interventions ( Table 1).

Statistical Analyses
To evaluate the efficacy of the Program in Kigoma region, we assessed health facility and pregnancy outcomes in public PS facilities and public and private non-program-supported (NPS) facilities at 3 points in time: 2013 (before the program interventions were scaled up), 2016, (after interventions were scaled up to additional centers), and 2018 (after dispensaries were added to the Program in 2016 and before closing the Program).
Before-and-after comparisons can only be performed for health facilities that initiated support after 2013. A baseline for facilities that started their interventions before 2013 cannot be established.
We present descriptive results as percentages, means, rates, and ratios by facility type, program support, and ownership status. All analyses were performed using SAS v. 9.6 software. Statistical tests were computed for rates and ratios only, using z-statistics.

RESULTS
In Kigoma, between 2013 and 2019, the capacity of facilities to deliver services improved and the health workforce increased. In the region, the number of health providers who provide skilled birth attendance increased by 64% between 2013 and 2018 (from 989 to 1,621) and the density of skilled birth attendants increased from 4.5 to 6.6 per 10,000 population (Table 2). However, at the end of the Program, despite improvements, the density of skilled birth attendants remains nearly 7 times lower than the minimum threshold recommended by WHO (44.5 per 10,000 population). 48 Select Service Components Needed for the Delivery of Routine Maternal Health Services Availability of basic infrastructure and readiness to provide routine and emergency obstetric and newborn services in Kigoma region generally improved across all domains examined (Table 3).
Despite the significant increase in skilled birth attendance from 2013-2018, the density of skilled birth attendants remains nearly 7 times lower than the WHO minimum threshold.  Density of health workers providing skilled care at birth a (per 10,000 population) 4.5 6.6 6.6 Health care facility types Abbreviations: AVD, assisted vaginal delivery; EmONC, emergency obstetric and neonatal care. a Includes obstetrician/gynecologists, surgeons, medical doctors, assistant medical officers, clinical officers/assistants, nurse-midwives, advanced practice nurses, and nurse assistants/medical attendants. b All program-supported dispensaries were upgraded for essential maternal and newborn care and family planning services; 18 dispensaries received additional support, mentorship, and supported supervision for basic EmONC; 49 dispensaries received additional support, mentorship, and supervision for family planning activities, including outreach activities. c EmONC includes a set of evidence-based lifesaving interventions or "signal functions" that the World Health Organization recommends for reducing maternal and neonatal mortality. 44 Basic EmONC interventions include administration of parenteral antibiotics, uterotonics, or anticonvulsants; manual removal of placenta; removal of retained products; assisted vaginal delivery; and basic neonatal resuscitation. Comprehensive EmONC interventions include 2 additional services: ability to perform obstetric surgery (e.g., cesarean delivery) and blood transfusion. Facilities were classified based on whether they had, within the previous 3 months, performed each of these interventions. Because assisted vaginal delivery-using either forceps or vacuum extractor-is relatively uncommon in Tanzania, some facilities were classified as fully providing EmONC care even if they did not perform assisted vaginal deliveries within the past 3 months. d A minimum of 25 EmONC facilities including at least 5 fully functional CEmONC facilities are recommended for the 2018 population size of Kigoma. 45,46 Improving Emergency Obstetric and Newborn Care in Sub-Saharan Africa www.ghspjournal.org Global Health: Science and Practice 2022 | Volume 10 | Number 2 Reliable power and clean water supply were available in almost all facilities in 2018 (92% and 93%, respectively) compared to only 76% (electricity) and 71% (clean water) in 2013. Almost all facilities reported no stock-outs of antibiotics (93%), uterotonics (99%), and magnesium sulfate (89%) in 2018. Availability of services 24/7 was reported by 98% of facilities in 2018, routine use of active management of the third stage of labor was documented in 96% of facilities, and availability and routine use of partographs was documented in 79% of facilities.
In general, hospitals had better infrastructure, essential drugs, routine maternal care, and availability of forms and protocols than heath centers and dispensaries.
A key component of monitoring and improving clinical outcomes is conducting maternal and perinatal death reviews, which are mandated by the Ministry of Health in all health facilities. The assessment found that maternal and perinatal review forms, a prerequisite to completing reviews, were present in one-third of all types of health facilities in 2018, a steep increase from 5% and 2%, respectively, in 2013.

Availability of EmONC Services
The capacity to provide EmONC services in Kigoma improved between 2013 and 2018, as reflected in the increased average number of signal functions performed-from 2.8 to 4.7 (a 68% increase) ( Table 4). Several lifesaving interventions became almost universal in 2018-administration of parenteral antibiotics (100%), uterotonic drugs (100%), and magnesium sulfate (93%)-and neonatal resuscitation was performed by 81% of health facilities in 2018, compared to 34% in 2013. However, the percentage of health facilities reporting current performance of MRP, obstetric surgery, and blood transfusion remained relatively unchanged. Performance of AVD was the least frequently performed lifesaving intervention, both in 2013 (10%) and 2018 (6%) ( Table 4).
While the number of health facilities (hospitals, health centers, and dispensaries combined) providing maternity care increased greatly, the proportion offering obstetric services that were classified as CEmONC (with or without AVD) remained relatively unchanged (8% in 2018 and 7% in 2013), whereas the proportion of BEmONC facilities (with or without AVD) almost doubled in 2018 (3%) compared to 2013 (1.6%).
CEmONC functionality increased in PS health centers. In 2018, health centers upgraded in the first group (PS-G1) and those upgraded in the second group 2 (PS-G2) performed, on average, at least 2 more signal functions than NPS health centers (7.8 and 8.1 versus 5.8 signal functions). A higher proportion of PS health centers performed AVD in 2018 compared to NPS health centers (67% of PS-G1 and 43% of PS-G2 versus 14% of NPS health centers). Similarly, more PS than NPS health centers performed MRP (50% of PS-G1 and 71% of PS-G2 versus 43% of NPS health centers). Making cesarean deliveries available at the health center level, one of the Program's original goals, was achieved and sustained at all but 1 PS health center. In 2018, 83% of PS-G1, 100% of PS-G2, and 21% of NPS health centers provided obstetric surgeries. As a result, 67% of PS-G1 health centers, 72% of PS-G2 health centers, and only 21% of NPS health centers functioned at the CEmONC level (with or without AVD) in 2018. In 2018, the majority of PS-G1 and PS-G2 health centers that were not classified as CEmONC were only missing 1 signal function; the most frequently missing services were MRP or AVD. One G1 health center had performed MRP and AVD (as well as the other 5 signal functions) but was missing blood transfusion and obstetric surgery and was classified as BEmONC.
The average number of signal functions provided at dispensaries receiving program support for EmONC services more than doubled in 2018 compared to 2013 (4.9 versus 2.3 signal functions). Dispensaries receiving family planning support and those not supported by the Program also reported substantial increases, averaging 4.3 and 4.0 signal functions, respectively, in 2018. Except for administration of injectable antibiotics and uterotonics in the last 3 months, which were universal across all dispensaries in 2018, performance of other signal functions that constitute BEmONC care was the highest in the EmONC-supported dispensaries (e.g., parenteral anticonvulsants, removal of retained products, and neonatal resuscitation).
Changes in availability and quality of maternity care were paralleled by improvements in pregnancy outcomes.

Institutional Delivery Rate
The institutional delivery rate in Kigoma in 2018 was 85%, a 74% increase from 2013 ( Table  5). The hospital delivery rate increased from 13.5% in 2013 to 14.0% in 2018, while the rate in health centers and dispensaries increased from 15% to 25% and from 21% to 46%, respectively. As a result, the relative contribution of hospitals to Improving Emergency Obstetric and Newborn Care in Sub-Saharan Africa www.ghspjournal.org Global Health: Science and Practice 2022 | Volume 10 | Number 2 the overall institutional delivery rate declined, the contribution of health centers remained relatively constant, and the contribution of dispensaries increased (from 42% to 54%) (data not shown). PS facilities, regardless the level of functionality, provided most of the delivery care in 2018 (63%) and 2013 (66%) ( Table 6). While deliveries in PS hospitals declined, deliveries at the PS health centers and dispensaries increased substantially. The highest percentage increase occurred in PS dispensaries that received EmONC support. Deliveries in all types of NPS facilities were also higher in 2018 compared to 2013. All changes in institutional delivery rates were significant.

Population Cesarean Delivery Rate
As more women with obstetric complications sought care in health facilities in 2018 compared to 2013, the number of cesarean deliveries almost doubled (Table 5). There was a 61% increase in hospital-based cesarean deliveries and a 4-fold increase in health centers. As a result, the population cesarean delivery rate in 2018 was 4.5%, a significant increase from 2.6% in 2013, and at the lower end of the WHO recommended optimal range of 5-15. 44 While most cesarean deliveries occurred in hospitals, the proportion of hospital cesarean deliveries of all cesarean deliveries was lower in 2018 (65%) compared to 2013 (78%), as more cesarean deliveries took place in health centers that became staffed and equipped to provide obstetric surgeries.
The cesarean delivery rate contributed by PS hospitals increased by 31% (from 1.6% to 2.1%) in 2018 while the rate contributed by PS health centers tripled (from 0.3% to 1%) ( Table 6). As a result, PS hospitals and health centers contributed 69% of the regional cesarean delivery rate (3.1% of 4.5%) in 2018. (Table 5 and 6). The cesarean delivery rate contributed by NPS hospitals and health centers increased at a slower pace (from 0.5% to 0.9% and from 0.3% to 0.5%, respectively). All cesarean deliveries that were performed in NPS facilities took place in private/faith-based hospitals and health centers and none were performed in governmental facilities (data not shown).

Met Need for EmONC in All Health Facilities
Almost two-thirds (61%) of women estimated to have developed obstetric complications (including first-trimester pregnancy complications) were treated in health facilities in 2018, a 40% increase compared to the 2013 level (44%) ( Table 5). While more than half of these women received care in hospitals, there was a higher increase in met need in health centers and dispensaries between 2013 and 2018, as compared to the increase in hospitals. About two-thirds of women with obstetric complications in the region received care in PS hospitals, health centers and dispensaries (3,997 of 5,769 women in 2013 and 6,200 of 9,217 women in 2018 (Table 5 and 6). The met need for EmONC was twice as high in PS than NPS facilities (41% versus 20% in 2018 and 31% versus 14% in 2013).

Direct Obstetric CFR
Concurrent with increases in met need for EmONC, the direct obstetric CFR declined as more women with complicated pregnancies received better treatment in health facilities (from  1.8% in 2013 to 1.4% in 2018) ( Table 5). There was a 33% decline in the CFR in PS facilities (from 2.1% in 2013 to 1.4% in 2018), while the CFR in NPS facilities did not change significantly ( Table 6).

Institutional MMR
The MMR in 2018 across all health facilities providing delivery care was 174 maternal deaths per 100,000 live births, 43% lower than 303 deaths per 100,000 in 2013 ( Table 5). As expected, hospital-based maternal mortality in both 2013 and 2018 was several times higher than mortality in health centers and dispensaries, due to referrals from lower levels among women who had obstetric complications and needed more advanced obstetric care. Changes in MMR from 2013 to 2018 by facility type were not statistically significant. Despite a significant 46% decline from its level in 2013 (386 per 100,000 to 208 per 100,000 in 2018) (Table 6), the MMR in PS facilities remained higher than the MMR in NPS facilities (208 per 100,000 versus 129 per 100,000 in 2018). The MMR in NPS facilities did not change significantly between 2013 and 2018.

Stillbirth Rate
The total stillbirth rate in Kigoma declined from 26.7 stillbirths per 1,000 total births in 2013 to 12.8 per 1,000 in 2018-a 52% decline (Table 5). Declines were substantial in hospitals (from 49.5 to 34.3 per 1,000), health centers (from 28.9 to 18.8 per 1,000) and in dispensaries (from 5.6 to 2.7 per 1,000). The decline was accompanied by a large reduction in the intrapartum stillbirth rate (from 14.4 to 6.0 per 1,000) and was sustained across all facility types. As a result, the contribution of intrapartum stillbirth rate to the total stillbirth rate declined from 54% to 47% between 2013 and 2018. The total stillbirth rates declined significantly in both PS and NPS facilities (from 29.8 to 16.0 per 1,000 and 20.5 to 8.4 per 1,000, respectively). In 2018, the total stillbirth rate in PS facilities was 1.9 times as high as the rate documented in NPS facilities-16.0 versus 8.4 per 1,000 (Table 6)-which corresponds with higher proportions of women who had obstetric complications treated at PS facilities. With an increase in the quality of care at birth, the declines in intrapartum stillbirth rate were seen in both PS and NPS facilities.

Predischarge Neonatal Death Rate
The predischarge neonatal mortality rate was 7.6 per 1,000 live births in 2018, a 29% decline from 10.7 in 2013 (Table 5). Neonatal mortality in 2018 continued to be about twice as high in hospitals than in health centers (22.9 and 11.6 per    Abbreviations: DHIS, district health information systems, EmONC, emergency obstetric and neonatal care; MMR, maternal mortality ratio; N/A, not applicable; Sig. Level, significance level. a Includes antepartum, intrapartum, and postpartum hemorrhage, eclampsia/preeclampsia, puerperal sepsis, obstructed labor/uterine rupture, other direct obstetric complications (e.g., embolism, anesthetic complications), and first trimester complications related to all pregnancy losses. b Asterisks indicate significance levels calculated with a z-statistic as follows: ***=P <.01, **=P <.05, *=P<.1, NS=not significant. c The institutional delivery rate in 2013 includes imputations using DHIS-reported number of deliveries for missing months of outcomes, which were primarily in dispensaries. All other indicators were calculated without these imputations, as DHIS only contains aggregate data. d The institutional delivery rate and the cesarean delivery rate use the expected annual number of live births in the regional population as denominators, as shown in Table 2.
Improving Emergency Obstetric and Newborn Care in Sub-Saharan Africa www.ghspjournal.org Between 2013 and 2018, the predischarge neonatal mortality declined significantly in both PS and NPS facilities, but the decline was less pronounced in PS facilities. The predischarge neonatal death rate was twice as high in PS than NPS facilities in 2018 (9.7 versus 4.9 per 1,000) and 1.5 as high in 2013 ( Table 6). The changes in neonatal mortality rates between 2013 and 2018 varied considerably depending on facility and program support type. There was an increase in neonatal mortality in PS hospitals and health centers, a decrease in NPS hospitals, and no significant change in NPS health centers. Neonatal mortality in PS dispensaries  was very low with no change, while the mortality in NPS dispensaries was higher and declined.

DISCUSSION
The Program significantly contributed to the government's goal of improving the availability and use of high-quality EmONC services in Kigoma. By decentralizing and then sustaining highquality skilled birth attendance and EmONC in lower-level facilities, strengthening referral systems, increasing demand for facility delivery, and working with communities and government systems at all levels, the Program was able to help the region meet nearly all the government objectives.
The Program provides an important example of a comprehensive approach to reducing maternal and neonatal mortality that was created by and for rural communities in Tanzania. The availability of EmONC services improved in Kigoma. The average number of EmONC signal functions provided at health facilities increased over time, showing a greater capacity to treat obstetric complications. An earlier assessment of EmONC functionality 49 found that PS-G1 health centers started at a similar level as PS-G2 facilities, meaning that they also had a large net improvement; but in the absence of a baseline for those facilities, we are unable to present their true improvement of EmONC functionality. A greater number of signal functions offered at lower-level Kigoma facilities means there is less need for women with obstetric complications to be referred to far-off hospitals, thereby preventing potentially life-threatening delays. The number of signal functions provided at a facility has been shown to be related to whether women bypass lower-level facilities for higher-level facilities; the more signal functions provided by a facility, the less likely it is to be bypassed. 50,51 Greater use of lower-level facilities closer to where women live was an important objective of the Program.
One of the primary goals of the Program was to enable health centers to provide obstetric surgery and that was achieved in all PS health centers and sustained over the program period in all but 1. Surgical services were sustained as a result of the comprehensive package of training and the clinical, managerial, and collegial support provided by the Program to the mostly associate clinicians and nurses involved. PS hospitals continued to provide the bulk of cesarean deliveries in the region but the addition of surgical capacity at the healthcenter level made a meaningful contribution to the region nearly meeting the United Nations recommended minimum acceptable level of cesarean deliveries per population of 5%. 44 While most EmONC signal functions were added and/or sustained in PS facilities, certain services were more difficult to maintain. The Program reintroduced AVD, a rarely used procedure in Tanzania, in Kigoma in 2011, and the many strategies described above were employed to ensure its sustained use. 52 However, continuous practice of AVD with a vacuum requires not only working equipment but the constant presence of knowledgeable and confident providers. 53 Thamini Uhai conducted a study in the Program's final months on providers' knowledge, attitudes, and practices and found that the best predictors of AVD performance were whether the provider had hands-on practice during training and had multiple exposures to learning opportunities, including the use of e-learning. 54 This may be the reason why AVD performance was lower than expected: the more comprehensive training with hands-on practice using manikins was introduced later in the Program and was not repeated enough for providers to retain their skills and confidence. MRP was also difficult to sustain in some PS facilities. This may have been because by 2018, all PS health centers and hospitals used active management of the third stage of labor, leading to fewer cases of retained placenta, and therefore making MRP less needed. It is essential, however, to ensure that providers maintain their skills and confidence in performing these 2 lifesaving interventions.
A national EmONC assessment conducted in 2015 55 on a census of Tanzanian health facilities providing maternity care and using a methodology adapted from the Averting Maternal Death and Disability Program, 56 found that a low proportion (5%) of facilities in the country provided BEmONC care and CEmONC care (5.4%) in the 3 months before the survey. These proportions compare to 1.7% and 5.2%, respectively, in Kigoma in 2016, and 3% and 7.7% in 2018, reflecting large gains in CEmONC and BEmONC availability in Kigoma between 2016 and 2018.
Between 2013 and 2018, the number of observed EmONC facilities in Kigoma almost doubled from 11 to 21. Considering its population, Kigoma would require at least 4 more EmONC facilities to meet the target recommended by WHO. 44 Attaining this target would not require construction of new structures; rather it would entail focusing on health centers and dispensaries offering fewer than 7 signal functions and determining what is needed to ensure they can provide By decentralizing and sustaining high-quality skilled birth attendance and EmONC in lowerlevel facilities, strengthening referral systems, increasing demand for facility delivery, and working with communities and government systems at all levels, the Program was able to help the region meet nearly all government objectives.
any missing EmONC services. Our experience shows that maintaining signal functions is difficult in low-resource, rural settings, even with a long, dedicated effort; however, regular implementation support and evaluation helped identify gaps in service provision, which could then be addressed through targeted interventions.
One of the biggest changes in Kigoma over the program period was the large, significant increase in institutional deliveries. The Program began by improving the quality of EmONC services at PS health centers and hospitals and saw some increases in institutional delivery. But, in later years, the Program's accelerated efforts to increase demand for facility care, improve women's childbirth experience, strengthen referral systems, along with efforts to improve quality of care at the dispensary level, played a large role in increasing the institutional delivery rate. Dispensaries, both supported and not supported, more than doubled the proportion of deliveries that they managed in the region and by 2018, they were managing more than half of all institutional deliveries. Studies have shown that women's choice of where to deliver is related to facility attributes (e.g., presence of providers with respectful attitudes and availability of drugs and medical equipment), perceived quality, experience of care, and distance, among other factors. 51,57-60 The Program's interventions worked to remove many of the barriers to institutional delivery that women face when deciding where to give birth and at the same time used evidence-based communication strategies to increase demand for facility deliveries. However, key to the program design was focusing on demand-side interventions only after EmONC services were increasingly available.
With the incremental increase in institutional deliveries in Kigoma, it was essential for the Program to develop methods to ensure and sustain the availability and quality of EmONC services so that women with obstetric complications would get effective, appropriate, and prompt treatment and avoid what Miller et al. call "too little too late" and "too much too soon." 61 Between 2013 and 2018, significantly more women with obstetric complications were managed with EmONC in Kigoma. By the end of 2018, almost two-thirds of women with expected complications in the region received treatment, with more complications treated in PS facilities. At the same time, the direct obstetric CFR declined significantly, indicating facilities' improved ability to identify and provide timely and appropriate treatment of obstetric complications in health facilities. Improved service delivery was accompanied by routine clinical audits and mentorship that helped ensure quality while controlling for overmedicalization. If Kigoma continues or accelerates its pace of improvement, especially with the leadership of the Regional Mentorship Team, the region is likely to continue increasing its met need for EmONC in the coming years. Met need for EmONC is inversely correlated with the MMR. 62 Facility-based maternal mortality and stillbirth rates declined in Kigoma by 43% and 52%, respectively, suggesting substantial improvements in the quality of care at birth. In addition to significant reductions in intrapartum stillbirths, antepartum stillbirths also declined most likely due to communities being better prepared to respond to danger signs during pregnancy along with improvements in antenatal care services implemented by the government and other partners in the region. 63 As a backdrop to program activities, national policies highlighting the importance of HBB training were introduced in Kigoma in 2015 along with a renewed national emphasis 64 on improving care for preterm and low birthweight babies through KMC. These policies likely contributed to the improved quality of newborn care in all facilities in the region. However, PS facilities treated most obstetric complications in the region and were able to decrease their direct obstetric CFRs, facility-based MMR, and stillbirth rates. But, PS facilities, particularly the 3 PS hospitals, saw the most complicated cases in the region, ultimately leading to higher mortality in those facilities as compared to NPS facilities. Continued efforts by stakeholders in the region to decrease delays in care of women with obstetric complications from reaching and receiving definitive treatment at EmONC facilities will reduce mortality rates further.
Between 2013 and 2018, predischarge neonatal mortality declined by 29% at the regional level. It remained high and unchanged in hospitals and was higher in PS facilities than in NPS facilities. Improved recording of neonatal deaths in PS facilities between 2013 and 2018 may have skewed predischarge neonatal mortality findings: death registers were introduced in maternity wards and dedicated perinatal death registers were introduced in facility morgues leading to more neonatal deaths recorded in 2018 than in 2013. In addition, all PS hospitals and most PS health centers introduced Helping Babies Breathe in 2016, which helped to correct a common misclassification of newborns with apnea as stillbirths rather One of the biggest changes in Kigoma was the large significant increase in institutional deliveries.
Improving Emergency Obstetric and Newborn Care in Sub-Saharan Africa www.ghspjournal.org Global Health: Science and Practice 2022 | Volume 10 | Number 2 than neonatal deaths leading to underreporting and/or misclassification of neonatal deaths in 2013; and with more PS facilities regularly conducting maternal and perinatal death reviews, classification of neonatal deaths became more accurate over time. Despite a regional decline, neonatal mortality before discharge remains high, indicating the need for better monitoring of newborns within the first 24 hours of life. Addressing staff shortages, especially cadres who can be trained to monitor newborns, is critical. Human resource shortages remain a major barrier to better quality of care in Kigoma.
The original program objective of transforming health centers into functional CEmONC facilities was achieved. By the end of the program, almost all PS health centers provided CEmONC services and they made a significant contribution to successfully treating women with obstetric complications. However, hospitals continued to play an important role in providing EmONC for the region, and increasingly, dispensaries play an essential part in Kigoma's health system.
Interventions at the district and regional levels, including continuing medical education, specialty trainings, and other district-and regionwide capacity-building efforts, most likely contributed to some of the important changes in NPS facilities as well. Further, there may be larger benefits to other areas of care, as the vast majority of health providers in the region are "generalists" and provide other services, not just delivery care, and most of the service delivery and managementrelated improvements would benefit health areas beyond maternal and newborn care (e.g., surgical capacity, infection prevention, availability of blood, and electricity). Going forward, Kigoma will continue to benefit from the Regional Mentorship Team's routine visits to all health facilities in the region.

Limitations
This article is not without limitations. First, HFAs captured the attributes of care at the time of the data collection. Facility readiness was not assessed continuously, and it is possible that certain aspects of readiness may have fluctuated during the year, particularly when it comes to adequacy of staffing, which can change from month to month. Performance of signal functions may also vary during the year, both due to changes in staffing, skills availability, caseloads, and temporary absences of essential commodities and supplies. Capturing signal function performance during the 3 months before the HFA, always conducted in January or February, may be conservative, as it reflects performance during the end of the previous year when we observed that fewer facility births occurred. Further, in defining CEmONC and BEmONC status, some facilities were classified as fully providing EmONC care even if they did not perform AVD within the past 3 months, as has been done in other countries. 3,65 Second, data quality and completeness improved during the evaluation years, particularly in PS facilities, where CDC and implementing partners conducted periodic trainings to strengthen the health information system. The documented decline in institutional MMR and perinatal mortality may therefore be underestimated, as it is likely that fewer deaths were recorded in registers in 2013. Third, ideally, program evaluation would have compared outcomes in the PS and NPS facilities from 2006 to 2018, but rigorous evaluation only began in 2013 and a true baseline cannot be established. In addition, even when pre-and postevaluation data were available to estimate changes in PS facilities, the results may have been confounded by general improvements in the region between 2006 and 2019 that were supported by efforts outside the Program.

CONCLUSION
Decentralizing high-quality CEmONC from hospitals to health centers, with care delivered mostly by associate clinicians and nurses, was successful and led to significant increases in the availability and utilization of lifesaving obstetric care in Kigoma. Sustaining high-quality CEmONC services at health centers required continuous support including routine supportive supervision, clinical audits, mentorship, and multiple methods of providing continuing medical education. With new programmatic components added over time, the Program was able to adapt to and meet the needs of women, their communities, health providers, and government officials and ultimately contributed to the reduction of maternal and perinatal mortality in the region.
The original program objective of transforming health centers into functional CEmONC facilities was achieved.
Improving Emergency Obstetric and Newborn Care in Sub-Saharan Africa www.ghspjournal.org Global Health: Science and Practice 2022 | Volume 10 | Number 2